Provider Demographics
NPI:1407988835
Name:JENSEN, REBECCA ELY (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELY
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:CLAIRE
Other - Last Name:ELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7301 N.58TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-1893
Mailing Address - Country:US
Mailing Address - Phone:623-842-8100
Mailing Address - Fax:
Practice Address - Street 1:7301 N 58TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1893
Practice Address - Country:US
Practice Address - Phone:623-842-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1648235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ592015Medicaid